COVID-19 Update

Monterey County Health Department, Bureau Edward L. Moreno, MD, MPH, Health Officer and Director of Public Health April 14, 2020 Current Situational Status As of April 12: 87 Laboratory-confirmed cases 20 Hospitalizations 3 Deaths 43% of confirmed cases have no known pre-existing medical condition that predisposes them to higher risk of severe disease Almost 550 contacts investigated and placed on home

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Testing Modalities Reverse Transcriptase Polymerase Chain Reaction (RT-PCR): Used by CDC, state and local public health labs, and some commercial labs Cepheid Xpert Nucleic Amplification Assay Test (NAAT): Many hospitals currently have equipment but are missing cartridges specific to SARS-CoV-2; 1-2 tests per hour Abbott ID Now COVID19: molecular point-of-care test; 5-20 minutes per test; limited number of test kits available

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Serologic Testing Only 1 CLIA-approved serologic test in U.S. to date Serologic tests measure antibodies to SARS-CoV-2, not the virus itself May be useful in helping to determine burden of disease on communities and guiding policy decisions

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Serologic Testing Cannot be used to determine if a person is currently infectious or if a person has COVID-19 disease Takes time after exposure to create antibodies, causing false-negative results if tested too soon after exposure Tests currently used without FDA approval may not be able to differentiate between SARS-CoV-2 and strains of seasonal coronavirus, causing false-positive results

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Local Testing Capacity Monterey County Public Health Lab is completing up to 80 tests per day, seven days a week, with 8 to 24 hour turn-around time Recently received additional test kits to extend testing capacity Priority testing like outbreaks in skilled nursing facilities increase the rate of testing and deplete testing supplies quicker

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Local Testing Capacity Hospital labs are working closely together to secure supplies for in-house testing, manufacture scare supplies, and set priorities for testing Commercial laboratory testing is available through ARUP, BioReference, Laboratory Corporation of America, and Quest with a turn-around time of 6 to 14 days

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Local Laboratory Testing as of April 12

Laboratory (FDA-Approved Tests) Positive Negative Total Resulted Percent of Results Results Tests Total Resulted Tests

Monterey County Public Health Laboratory 1,452 75% Monterey County Residents 71 1,158 1,229 Other County Residents 223 Other Public Health Laboratories 1 4 5 <1% Commercial Laboratories 12 337 349 18% Hospital Laboratories 3 116 119 6% Outpatient Clinic Laboratories 0 5 5 <1% Total 87 1,930 100%

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Barriers to Testing Limitations in the supply of: Testing reagents and cartridges specific to SARS-CoV-2 Swabs and viral transport media Microbiologists skilled in DNA extraction and PCR methods Personal protective equipment Medical staff trained and willing to collect specimens in the outpatient environment

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Purposes of Statistical Models

1. Estimate benefits of 2. Plan for increased social distancing in resource needs before reducing burden on hospital systems are health care systems overwhelmed

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Model Limitations 1. Models were developed for areas with large populations and with high burden of disease 2. Models applied to areas with smaller numbers of cases like Monterey County may be less robust 3. Model estimates vary greatly with small changes to model inputs 4. Model estimates improve as the advances 5. No model can accurately predict complex situations

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Models Explored 1. Stanford University – Systems Utilization Research for Stanford Medicine (SURF) 2. University of Washington – Institute for Health Metrics and Evaluation (IHME) 3. University of Pennsylvania – COVID-19 Hospital Impact Model for (CHIME)

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. CHIME Model Inputs Monterey County population Timing of implementation and level of compliance with social distancing measures Rate of case doubling at beginning of epidemic Percent of cases that are hospitalized and number currently hospitalized Percent of cases that require critical care and mechanical ventilation

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. 231,000

113,000

75,600

33,000

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. 9,300

3,500

2,200

900 Surge Potential=954

Licensed beds=678

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. 2,300

920

570

235 Licensed Critical Care Bed=33

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. 1,960

815

500

210 Ventilators on Site=158

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Estimated Effect of Social Distancing No Mitigation: Number of cases doubles every 2.0 days, 1 infected person spreads the disease to 5 others, daily growth rate of 41%. ◦ Doubling rate of 2 days seen in local data before Shelter in Place Order

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Estimated Effect of Social Distancing 50% Compliance: 50% reduction in social contact after onset of epidemic reduces doubling time to 4.8 days, Rt declines to 2.6 people per 1 case, and slows daily growth rate to 16%. ◦ Local data shows doubling rate ranged from 3 to 6 days from March 15 to March 30 ◦ Community efforts have been successful in slowing the spread of disease

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Local Hospital Care and Surge Capacity Hospitals have been planning for surge for several years and specifically for this event since early January Hospital staff coordinate collaborative calls at least twice weekly across the healthcare system Hospital staff provide guidance and trainings to local outpatient providers and congregate living facilities Hospital subject matter experts participate in the Monterey County Emergency Operations Center, provide technical advice, and help plan alternate care sites

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Ongoing Containment Measures 1. Implementation of and adherence to Health Officer Order to Shelter in Place 2. Health care provider and laboratory reporting of suspected cases of COVID-19 3. Investigations of diagnosed cases and their contacts

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Ongoing Containment Measures 4. Home isolation and quarantine to prevent further spread 5. Fast turn-around times for testing at Public Health Laboratory to guide hospital infection control decisions 6. Screening procedures at hospitals and outpatient care locations to quickly identify and isolate individuals with respiratory symptoms

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Case Investigations & Contact Tracing Identify and get in touch with every person diagnosed with COVID-19 Interview cases to identify all individuals with whom cases have had contact during the case’s infectious period Get in touch with every contact elicited as part of the investigation process Test all contacts for COVID-19

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Case Investigations & Contact Tracing Isolate ill individuals and COVID-19 positive individuals; conduct new case investigations for each of them Quarantine all asymptomatic and COVID-19 contacts through their incubation period Highly resource-intensive process (staff, PPE, testing)

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. De-escalation Planning Early local data demonstrates the community’s efforts to increase social distancing has helped “bend the curve” and avoid large hospital surges Social distancing has both social and economic impacts

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. De-escalation Planning Regional Health Officers and Health Directors are now reviewing impacts of containment and social distancing strategies to develop criteria that could be used in deciding when Shelter in Place orders could be modified to be less restrictive for certain populations Requires a balance between the social and economic benefits of modified Orders, the impact of COVID-19 on vulnerable populations that have not yet been infected, and the impact on the health care system

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Key Messages 1. Models are a tool to assist with preparedness planning but must be interpreted and utilized carefully. Models likely overestimate scale but appear to reflect local effects of social distancing. 2. Social distancing measures implemented early in the local epidemic appear to have reduce the rate of spread of COVID-19 locally. 3. Stricter measures and additional compliance with social distancing may help prevent local health care systems from being overwhelmed with a surge of patients requiring hospitalization and critical care. 4. Planning efforts are underway to prepare for future potential surges and the recovery phase of epidemic.

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond. Questions?

Monterey County Health Department, Public Health Bureau Prevent. Detect. Respond.